Management Options: Drug Therapy Requiring Intensive Monitoring for Toxicity

Published 08/03/2020

The table of risk lists drug therapy requiring intensive monitoring for toxicity as a high risk management option.

For drugs with a well-defined clinical response and a high therapeutic index (i.e., low toxicity), intensive therapeutic drug monitoring is not necessary. For acute or short-term drug therapy, there is no advantage to monitoring drug levels. For treatment of chronic disorders, such as antihypertensive therapy, if the desired response can be readily assessed by a noninvasive technique, such as blood pressure monitoring, serial drug level monitoring is not medically necessary.

Administration of cytotoxic chemotherapy is always considered high risk under management options when monitoring of blood cell counts is used as a surrogate for toxicity.

Drugs that have a narrow therapeutic window and a low therapeutic index may exhibit toxicity at concentrations close to the upper limit of the therapeutic range and may require intensive clinical monitoring. The table below lists examples of drugs that may need to have drug levels monitored for toxicity. This is not an all-inclusive list. On medical review, to consider therapy with one of these drugs as a high risk management option, we would expect to see documentation in the medical record of drug levels obtained at appropriate intervals.


Table of Risk
Drug Category
Digoxin, Digitoxin, Quinidine, Procainamide, Amiodarone
Congestive heart failure, angina, arrhythmias
Coumadin and intravenous Heparin drip (Heparin must be provided in the hospital setting)
Prevention of thrombosis and thromboembolisms
Phenobarbital, Phenytoin, Valproic Acid, Carbamazepine, Ethosuximide, sometimes Gabapentin, Lamotrigine
Epilepsy, prevention of seizures, sometimes to stabilize moods
Theophylline, Caffeine
Asthma, chronic obstructive pulmonary disorder (COPD), neonatal apnea
Cyclosporine, Tacrolimus, Sirolimus, Mycophenolate Mofetil, Azathioprine
Prevent rejection of transplanted organs, autoimmune disorders
All Cytotoxic agents
Multiple malignancies
Lithium, Valproic Acid, some antidepressants (Imipramine, Amitriptyline, Nortriptyline, Doxepin, Desipramine)
Bipolar disorder (manic depression), depression
Protease Inhibitors
Indinavir, Ritonavir, Lopinavir, Saquinavir, Atazanavir, Nelfinavir
Aminoglycosides (Gentamicin, Tobramycin, Amikacin) Vancomycin, Chloramphenicol, Cubicin, Zyvox
Infections with bacteria that are resistant to less toxic antibiotics
Intravenous Insulin drip
Erythropoiesis-Stimulating Agents (ESA)
Procrit and Epogen (Epoetin Alfa) and Aranesp (Darbepoetin Alfa)

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